CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3 4.000000 148.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 17 20.000000 744.0000 37.2000
Subtotal (Total Children Is Unduplicated) 20 24.000000 892.8000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 3 3.000000 154.2300 51.4100
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 27.250000 1375.0000 50.4587
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 274 2008.000000 100400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 32.000000 1600.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 778 5664.000000 84795.0000 14.9709
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 327 2103.000000 25188.0000 11.9772
OCCT-97530-OT SESSION BY LICENSED OT 3 10.000000 663.5600 66.3560
OCCT-97530HM-OT SESSION BY OT ASST 5 8.000000 460.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 8 39.000000 2806.4400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 3 23.000000 1323.8800 57.5600
Subtotal (Total Children Is Unduplicated) 1121 9914.250000 218612.6800 22.0504
-----------------------------------------------------------------------------------------------------------------------
Total 9941.250000 219659.7100 22.0958
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1139
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 2513 9888.250000 218106.1100 218016.1100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 22.000000 288.0000 225.0000
T 0 0.000000 0.0000 0.0000
41 24.000000 892.8000 0.0000
Other 3 7.000000 372.8000 172.8000
---------------------------------------------------------
Total 2565 9941.250000 219659.7100 218413.9100